Read Immunization Update - Spring 2005, New York State Department of Health text version

Immunization Update

New York State

Spring 2005 New York State Department of Health

Dear Colleague: This is the thirty-seventh issue of the New York State Immunization Update. The purpose of the Update is to provide the latest information on immunization-related topics. We invite you to share your ideas and concerns regarding both the Update and immunization issues in general. You may submit correspondence or a request to be added to the mailing list to the New York State Department of Health, Immunization Program, Room 649, Corning Tower, ESP, Albany, NY 12237-0627, or call (518) 473-4437 or e-mail [email protected]

The Registry Grows Like a Cooperative Garden

By Linda Markell Public Health Educator, Onondaga County Health Department

The Central New York Immunization Registry (CNYIR) continues to grow with over 1.3 million shots recorded and over 88,000 children enrolled. By November 2004, 265 medical practices had joined, representing almost 80% of the 14-county region's pediatric providers. As childhood immunization schedules become more complex, registries are essential tools helping to keep children up-to-date with immunizations and helping to maintain high levels of community immunization coverage rates. Provider offices in the Central New York (CNY) region have demonstrated improved immunization coverage rates when they use the registry. This requires commitment and investment of staff time to fully implement the CNYIR's HealthyShot software. Finding the time needed to participate in the registry can be challenging for a busy medical office staff. The Onondaga County Health Department, lead agency for CNYIR, and Partners in Health Systems (PHS), contractor for development, implementation and day-to-day management, co-created the Adopt-a-Site campaign to address challenges within participating provider offices. The Adopt-a-Site campaign designed a system for local health department staffers across the CNY region to mentor selected provider offices and bolster their progress toward full registry implementation. It developed campaign tool kit materials to help assess levels of utilization activities in provider practices, to identify staff concerns and issues, and, next, to help develop solutions to barriers. A key element in the Adopt-a-Site campaign is the use of gold standards for a fully functioning registry. Local health departments in the CNY region and PHS established the gold standards to measure a practice's progress toward the ultimate goal of achieving and maintaining 90% immunization coverage levels for two-year-old children. They include the following components: 1. Enroll 95% of children from birth up to age six years in the registry. 2. Record all immunizations within one month of administration. 3. Send data at least monthly to the CNYIR. 4. Use HealthyShot reporting capabilities such as: Immunization Histories/Physical Exam Reports Track and Recall Report Vaccine Inventory Module Vaccine For Children (VFC) Reporting Data Quality Reports Lead Test Reporting The Adopt-A-Site mentoring initiative is underway. This dynamic partnership among local health departments, Partners in Health Systems, the New York State Department of Health, and providers' offices will guide practices toward full implementation. A fully functioning continued on page 3 1


The Diabetes, Flu, and Pneumococcal Connection . . . . . . . 2 Flu Vaccine Shortage . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Migrant Worker Flu Initiative . . . . . . . . . . . . . . . . . . . . 3 NYSIIS Revises Birth Consent Form . . . . . . . . . . . . . . . . . 3 Varicella and Pertussis Protection . . . . . . . . . . . . . . . . . 4 Pertussis Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Sentinel Influenza Surveillance Network . . . . . . . . . . . . . . 5 Get Hip on Hep B . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 County Jail Hepatitis Vaccination Program . . . . . . . . 6 Adult Hepatitis Vaccination Program. . . . . . . . . . . . . 6 Birthing Hospitals Adopt Universal Hepatitis B Birth Dose Policy . . . . . . . . . . . . . . . . . . 7 Hepatitis Training Curriculum Created . . . . . . . . . . . 8 New Hepatitis Materials Available . . . . . . . . . . . . . . 8 Integrated Risk Assessment Tool Piloted . . . . . . . . . . . 9 Certificates of Excellence. . . . . . . . . . . . . . . . . . . . . 9 Standing Orders for Hepatitis A . . . . . . . . . . . . . . . . 10 Standing Orders for Hepatitis B. . . . . . . . . . . . . . . . . 11 Forging New Relationships-- The Amish Connection . . . . . . . . . . . . . . . . . . . . . . . . 12 PBIIs Registry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 New Audit of Schools . . . . . . . . . . . . . . . . . . . . . . . . 14 PBII Certificates of Excellence . . . . . . . . . . . . . . . . . . . . . 15

The Diabetes, Flu, and Pneumococcal Connection

Diabetes has reached epidemic proportions in the United States in the past 10 years. More than 18 million Americans have diabetes. Now the sixth leading cause of death in America, diabetes is responsible for over 200,000 deaths each year. The number of Diabetes is U.S. adults diagnosed with responsible for over diabetes, including women with gestational diabetes 200,000 deaths (diabetes that develops during each year pregnancy), has increased 61% since 1991 and is projected to more than double by 2050. Diabetes can cause heart disease, stroke, blindness, kidney failure, pregnancy complications, lower extremity amputations, and can contribute to deaths related to flu and pneumonia. Particularly at risk for these complications are the 5.2 million Americans who are unaware that they have diabetes. There are two main types of diabetes. Type 1 most often appears during childhood or adolescence. Type 2 diabetes, which is linked to obesity and physical inactivity, accounts for 90%­95% of diabetes cases and most often appears among people older than 40. However, it is no longer considered an adult-only disease. Type 2 is now being found at younger ages and is even being diagnosed among children and teens. Research has shown that type 2 diabetes can be prevented or delayed in persons at risk for the disease through moderate changes in lifestyle. Diabetes has its greatest effects on the elderly, women, and certain racial and ethnic groups. African American, Hispanic, American Indian, and Alaska Native adults are two to three times more likely than white adults to have diabetes. In addition to the millions of Americans with diabetes, an estimated 41 million U.S. adults aged 40­74 have prediabetes, meaning their blood sugar level is elevated but is not high enough to be classified as diabetes. People with pre-diabetes are at high risk for developing diabetes. People with diabetes are at higher risk for complications of influenza and pneumococcal disease. Although people with diabetes are almost three times more likely to die from influenza, about 50% do not get an annual flu shot. Pneumococcal disease kills more people in the United States each year than all other vaccine-preventable diseases combined, and people with diabetes are at greater risk. Getting these vaccines is a safe and easy way to protect the health of individuals with diabetes. Doctors, health-care providers, and local health departments are all good sources of information on dates, times and places where influenza vaccines are given. Both influenza and pneumoccocal vaccines are covered by Medicare, Part B. For more information on diabetes, contact your local health department, visit the New York State Department of Health (NYSDOH) website at or or call the NYSDOH Diabetes Prevention and Control Program at 518-474-1222. 2

Flu Vaccine Shortage -- New York Steps Up to the Plate

On October 5, 2004, the Centers for Disease Control and Prevention (CDC) announced that the Medicines and Healthcare Products Regulatory Agency in the United Kingdom had suspended the manufacturing license of Chiron Corporation. As a result, none of the influenza vaccine (Fluviron ®) manufactured by the Chiron Corporation was available for distribution in the United States for the 2004-2005 season. This action reduced the nation's projected supply of vaccine for the 2004-2005 influenza season by approximately one half. This season's vaccine shortage created challenges regarding how to best provide vaccine for New York State residents who were in a priority group for vaccination. After the October 5 announcement, the New York State Department of Health (NYSDOH), in collaboration with CDC, county health departments and the New York City Department of Health and Mental Hygiene, worked with hospitals, physicians, and other health-care providers to ensure an equitable distribution of available influenza vaccine supplies to persons in priority groups. The NYSDOH developed a fair and comprehensive plan to distribute the existing supply of influenza vaccine available in New York State. The department monitored influenza activity and vaccine supplies throughout the state by using its innovative Health Emergency Response Data System (HERDS) to collect information from hospitals. The system can pinpoint where vaccine shortages and supplies exist, making it possible to quickly redistribute supplies where they are needed. The department also conducted periodic surveys of all county health departments, diagnostic and treatment centers, nursing homes, and adult homes that care for high-risk populations to determine the vaccine supply and need across the state. It distributed influenza vaccine to hospitals, long-term care facilities, private health-care providers, and local health departments throughout New York State. The local health departments used this vaccine to immunize high risk individuals, and/or made this vaccine available to those who care for high-risk individuals. The NYSDOH also provided information to the public and providers during this emergency period, such as educational materials and posters that are available on its website, or These materials address frequently asked questions about influenza disease and vaccine, and provide information on disease control and updates on the influenza vaccine supply. All providers and patients can benefit from investigating the resources available on this website.

NYSDOH Spearheads Migrant Worker Flu Initiative

Migrant workers in New York State (NYS) are the focus of an initiative to improve their influenza immunization coverage. After a 2002 National Immunization Survey indicated that the influenza coverage level for high-risk individuals ages 18-49 was 23%, New York State's Immunization Program has targeted various high-risk populations, migrant workers among them. More than half of the migrant population in NYS is over 19 years of age, Hispanic, single and male. In 2003, the NYSDOH Immunization Program assessments indicated that adult migrants were not adequately immunized. Provider record reviews showed that influenza was the primary vaccine being administered in this population through migrant health programs, which were able to offer influenza through their federally funded grants. The Immunization Program believed that migrants should have access to other vaccines and be educated about their benefits. In 2003, the Immunization Program included the migrant population in its adult immunization activities and began to develop partnerships with migrant programs and organizations, and community/migrant health centers. It added an objective in its 2003 and 2004 Centers for Disease Control and Prevention grant application to (1) expand partnerships with migrant health programs, (2) supply vaccines through local health departments on a pilot basis, and (3) improve accountability of administered vaccines. In September of 2003, the Immunization Program initiated a Western Region Pilot Project to educate adult migrants on the benefits of immunization and to increase access to vaccines. Project participants included the counties of Niagara, Wayne, Ontario, Yates, Steuben, Livingston, Chautauqua, Orleans, Genesee and Monroe. The initial outcome was successful; out of 10 counties, seven utilized vaccines for their migrant populations. Local health departments began to fully collaborate with migrant programs and close to 1,000 vaccines were administered to migrants in the first year. In 2004, the Immunization Program continued to expand this initiative to the remaining counties serving migrant populations. The expansion includes supplying vaccines to three federally qualified health centers in Upstate NY: Finger Lakes Migrant Health, Hudson River Health Care and Oak Orchard. The NYSDOH is currently developing a poster and brochure for the migrant population on adult immunizations. These activities will continue through 2005.

NYSIIS Revises Birth Consent Form

The New York State Immunization Information System (NYSIIS), New York State's (NYS) immunization registry, recently revised its consent form that is included in the Statewide Perinatal Data System (SPDS) workbook for parents to sign at their child's birth. The consent allows NYS Vital Records to disclose information to NYSIIS. The information includes the child's and parents' names and address and whether or not the child received the recommended hepatitis B birth dose. When families participate in NYSIIS, their health-care provider is better able to ensure that they are adequately immunized. The value of birth information is not lost on the Centers for Disease Control and Prevention (CDC), which has included among its 12 Functional Standards for Immunization Information Systems the requirement that a registry record be established within six weeks of birth. In addition to the Functional Standards, CDC has set a Healthy People 2010 goal that immunization registries have 95% of children under six years of age with two or more shots participating in a registry. The birth record is the best means to ensure the 2010 goal is reached. The NYSIIS staff began working with the New York State Department of Health's (NYSDOH) Office of Vital Records early in 1996. Since then, there has been a NYSIIS parental consent in the birth workbook allowing the exchange of information between the electronic birth certificate and NYSIIS. In 2004, Vital Records began revising the workbook and in October asked the Immunization Program to update the consent, with the assistance of the NYSDOH's Division of Legal Affairs. That office advised that the section which alludes to NYSIIS redisclosing birth information to schools and day cares should be made consistent with the federal Health Insurance Portability and Accountability Act (HIPAA). The language was amended and the consent subsequently forwarded to the state's birthing hospitals. The revised consent is significantly different from the previous consent and has raised many questions from hospital personnel. The Immunization Program is currently working to clarify this important document and provide additional information to birthing hospitals and other interested parties. For information related to the NYSIIS consent document, call the Immunization Program at (518) 474-1944.

The Registry Grows continued from page 1 system will benefit all registry users by ensuring up-todate records to reduce missed vaccination opportunities, to reduce school inquiries, to help keep patient care consistent as children transfer in and out of various practices, and ultimately to reduce vaccine-preventable illnesses among children. Registry expansion and implementation requires ongoing support from many levels with medical practices playing a critical role in our success. Continued commitment and collaboration among all stakeholders will support expansion of the registry and propel it toward a fully functioning and mature system. For more information about the CNYIR, call Katie Reed, Vice President, Partners in Health Systems, at (315) 446-1612 x7217 or Kathy Mogle, Public Health Educator, Onondaga County Health Department, at (315) 435-3280. 3

Varicella and Pertussis Protection Added to School Requirements

Varicella and pertussis have been added to the list of diseases that children must be immunized against to get into school. New York State Public Health Law Section 2164 was amended twice in 2004 to update immunization requirements for school entry that take effect January 1, 2005. The first amendment requires students who will be enrolled in the sixth grade in 2005 to be immunized against varicella. The second amendment mandates that all children born on or after January 1, 2005, be immunized against pertussis and tetanus as requirements for school entry and attendance. According to Public Health Law Section 2164, a "school" means any public, private, or parochial child caring center, day nursery, day care agency, nursery school, kindergarten, elementary, intermediate or secondary school. Specifically, the varicella amendment requires the following: · Students born on or after January 1, 1994, and who enroll in the sixth grade at the beginning of the 2005 ­ 2006 school year must be immunized against varicella. · Students born on or after January 1, 1994, and who transfer to a school in New York State from another state or country after January 1, 2005, must be immunized against varicella at the time of school entry. · Special Education students in gradeless classes who were born on or after January 1, 1994, must be immunized against varicella at the start of the 2005-2006 school year; · Students born on or after January 1, 1994, who are repeating the sixth grade at the beginning of the 2005 ­ 2006 school year are required to be immunized against varicella. Exemptions from this requirement include the following: · A history of varicella disease as documented by a physician. Parental recall of the disease history is not sufficient, and will not be accepted as proof of immunity. · A medical exemption consisting of a written statement from a physician licensed to practice in the State of New York stating that there is a valid medical contraindication to varicella vaccine. A copy of the exemption must be retained by the school. · A statement of religious exemption written by a parent or guardian of the child stating that they hold sincere and genuine religious belief(s) which prohibit the immunization of the child. The request for exemption must be approved by the school. A copy of the exemption must be retained by the school. Secular principles, including philosophical exemptions, are not allowed. · Serologic proof of immunity to varicella. The serologic test is reliable for determining the immune status in a healthy person after a natural infection, but may not be reliable in immunocompromised persons. The amendment regarding tetanus and pertussis mandates that children born on or after January 1, 2005, be immunized against these diseases as a requirement for entry and attendance to any school defined by this law. The only exceptions to immunization against pertussis and/or tetanus are the aforementioned medical or religious exemptions. Questions regarding these new immunization requirements may be directed to the New York State Department of Health's Immunization Program at the following telephone numbers: Central Office Capital District Regional Office Western Regional Office Rochester Field Office Syracuse Regional Office New Rochelle Field Office Central Islip Office Monticello District Office Metropolitan Area Regional Office (518) 474-1944 (518) 408-5278 (716) 847-4385 (585) 423-8090 (315) 477-8164 (914) 654-7194 (631) 851-3081 (845) 794-2045 (212) 268-7276

Tri-Pak Not Adequate Pertussis Treatment

Is "Tri-Pak," the three-day course of azithromycin, an adequate option for pertussis prophylaxis or treatment? After consulting with physicians at CDC, the NYSDOH recommends the following: Tri-Pak is a three-day course of the macrolide antibiotic azithromycin, consisting of 500 mg once a day for three days. It is not considered adequate treatment or prophylaxis for pertussis because there are no data to support the effectiveness of this regimen at this time. When using azithromycin for pertussis prophylaxis or treatment, adequate dosage is 10 mg/kg/day in one daily dose, for five days. "Z-Pak," which consists of azithromycin 500 mg in a single dose on day one, 4 followed by 250 mg in a single dose on days 2-5, is also an acceptable treatment. Persons who have been started on Tri-Pak should be continued on azithromycin at the 500 mg or 250 mg dose for two additional days. If there has been interruption in treatment of more than one day, a new five-day course of azithromycin, as outlined above, should be prescribed. Please feel free to share this information with providers in your community. For additional information, please contact your regional New York State Department of Health Immunization Program representative or the Immunization Program central office at (518) 473-4437.

Sentinel Influenza Surveillance Network Growing

The New York State Department of Health (NYSDOH) sentinel physician influenza surveillance network continues to provide valuable clinical and virologic information regarding state, national and global influenza surveillance. Since its inception in 1998, the network has grown from seven to 115 sentinels. New York State (NYS) sentinel physicians are part of a 1600-member, nationwide network sponsored by the Centers for Disease Control and Prevention (CDC). Because influenza is not a reportable disease in most states, the CDC secures weekly reports of influenza-like illness (ILI) and patient specimens from volunteer health-care providers. This information, combined with other influenza surveillance data, is used to monitor the timing, location, impact and relative circulation of influenza viruses from October through May of each influenza season. Year-round surveillance is encouraged to help establish baseline data for the State.


Sentinels using the CDC internet reporting system can easily link to regional and national influenza updates. Weekly updates for New York State can be accessed at The data that sentinel physicians provide are summarized in the weekly updates. Participants also receive annual subscriptions to the journal Emerging Infectious Diseases One to four million and CDC's Morbidity New York residents and Mortality Weekly Report. become infected during

Importance of Sentinel Data

Influenza Reporting

NYS sentinels have reported on over 400,000 patient visits to date during the 2004-05 influenza season. Approximately 1.9% of those patients were diagnosed with influenza-like illness (defined by CDC as fever 100°F and cough or sore throat in the absence of a known cause). About 27% of these were in the 0-4 year age group and another 42% were in the 5-24-year age range. Weekly percentages of office visits for ILI range from 0.5% to 3.2% for the State at the height of the influenza season. Nationally, office visits for ILI in excess of 2.5% correlate with annual epidemic activity. Influenza surveillance in New York State consists of monitoring influenza outbreaks in nursing homes and hospitals, data from the State's health-care facilities and laboratories that collaborate with the World Health Organization (WHO), data from the National Respiratory and Enteric Virus Surveillance System (NREVSS) networks, and information (percent ILI) reported by sentinel providers. Sentinel surveillance has proven to be an effective component of the influenza monitoring system. For each of the past five seasons, the NYS sentinel surveillance system has identified the onset, peak and duration of influenza activity. Sentinel data often identify trends before laboratory data become available.

Influenza viruses are constantly evolving and cause substantial morbidity and mortality almost every winter. One to four million New York residents become infected during a typical influenza season, resulting in approximately 12,000 hospitalizations and over 2,000 deaths annually. The data that sentinel physicians provide, in combination with other surveillance data, are used to guide influenza prevention and control activities.

a typical influenza season, resulting in approximately 12,000 hospitalizations and over 2,000 deaths annually.

More Sentinels Are Needed

The CDC seeks one sentinel health-care provider for every 250,000 residents. Sentinels are needed in all areas of the State. In particular, more sentinels in the major cities are needed. Physicians who specialize in geriatrics or whose patients are mainly in the > 65 age range are underrepresented as a group among sentinel providers. More are needed to reflect the age distribution of the population. Physicians, physician assistants, nurse practitioners, and school nurses from any specialty and any practice type are invited to enroll. Sentinels report the number of patients seen with ILI in four broad age categories and the total number of patients seen each week. Reports are submitted to the CDC via the Internet, fax, or phone. The entire process takes from 15 to 30 minutes each week. Materials to collect and ship six patient respiratory specimens during the season are provided without cost. Rapid antigen testing, culture, typing, and subtyping are performed by the NYSDOH virology laboratory without cost. Please contact Pam Duncan of the New York State Department of Health at (518) 486-2938, [email protected] or (for providers located in New York City) Beth Nivin of the New York City Department of Health and Mental Hygiene at (212) 788-9830, [email protected] to receive more information or to volunteer to participate in this valuable public health service.

Specimen Collection

Specimens collected at the season's onset are used to assess the match between circulating viral strains and those covered by the current vaccine. Specimens collected at the season's midpoint and end assist the CDC and the WHO in determining strains for inclusion in next year's vaccine. The CDC also seeks specimens from unusually severe or outbreak-related cases of influenza, as part of its continuing surveillance for novel influenza subtypes which could lead to the next influenza pandemic.


County Jail Hepatitis Vaccination Program Gains Momentum

The Centers for Disease Control and Prevention (CDC) has shown that incarcerated persons have a disproportionately greater burden of infectious diseases, including infections with hepatitis viruses, than the nonincarcerated population. Improved access to medical care and prevention strategies for incarcerated populations has the potential to benefit all communities through reduced disease transmission and lower medical costs. Additionally, inmates who participated in health-related programs while incarcerated have lower recidivism rates and are more likely to maintain health-conscious behaviors (MMWR, Jan. 29, 2003, Vol. 52/No. RR-1). During 2003, the Immunization Program began a pilot project to provide free hepatitis A, hepatitis B and Twinrix® vaccines through local health departments to inmates in their county jails. What started as a relatively small program, with 10 counties originally in the pilot, has grown to 25 counties currently participating, and several other counties expressing an interest in joining the initiative. CDC recommends that all inmates receive hepatitis B vaccine. In addition, susceptible inmates in certain high-risk groups should receive hepatitis A vaccine. If an inmate is at risk for both hepatitis A and B viruses, then Twinrix® (combination hepatitis A

The following risk groups should be considered for both hepatitis A and hepatitis B vaccines: · Men who have sex with men · Injectable drug users · Persons with chronic liver disease, including hepatitis C

and B vaccine) may be administered. Those falling into the following risk groups should be considered for both hepatitis A and hepatitis B vaccines: · Men who have sex with men · Injectable drug users · Persons with chronic liver disease, including hepatitis C For more information about the County Jail Hepatitis Vaccination Program, please contact Elizabeth Herlihy at [email protected] or phone (518) 473-4437.

Adult Hepatitis Vaccination Program Targets High Risk Adults and Adolescents

The "Adult Hepatitis Vaccination Program" provides free hepatitis A, hepatitis B, and Twinrix® (combination hepatitis A and B) vaccines to county health departments targeted to high-risk adults and adolescents presenting to all service sites, including county locations. Common sites where the vaccines are administered include sexually transmitted disease (STD) clinics, HIV/AIDS counseling and testing sites, tuberculosis clinics, adult immunization clinics, and county jails. High-risk adults and adolescents presenting to all settings served by the county health departments should be 6 assessed for their risk of viral hepatitis and offered hepatitis vaccines, if indicated. Risk groups for viral hepatitis are outlined in the hepatitis A and B standing order documents, and are based on recommendations of the Centers for Disease Control and Prevention. The standing orders are published by the Immunization Action Coalition.and are printed in this publication. For more information about the "Adult Hepatitis Vaccination Program" you may contact Elizabeth Herlihy, Hepatitis B coordinator, at [email protected] or call (518) 473-4437.

Birthing Hospitals Adopt Universal Hepatitis B Birth Dose Policy

The Hepatitis B Birth Dose Program has enrolled 55 out of 110 upstate birthing hospitals since the initiative began in October 2003. The program provides free hepatitis B vaccine to any birthing hospital in New York State that agrees to adopt a universal hepatitis B birth dose policy. Hospitals may participate in the program by submitting a brief application, along with their birth dose policy and standing orders, to the New York State Department of Health (NYSDOH) for review. The policy must clearly show that all newborns will be routinely vaccinated against hepatitis B at birth, regardless of maternal HBsAg status, infant's insurance status, or individual physician preference. The preference for the first dose of hepatitis B vaccine to be administered to all infants at birth is endorsed by the American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), the American College of Obstetricians and Gynecologists (ACOG), and the Advisory Committee on Immunization Practices (ACIP). The provision of hepatitis B vaccine to all infants at birth provides a "safety net" to high-risk infants who do not receive appropriate prophylactic treatment to prevent hepatitis B virus (HBV) transmission at birth, and to infants who are exposed to HBV postnatally from another family member or caregiver. Although New York State has a law mandating that all pregnant women be tested for HBsAg and all infants born to positive HBsAg mothers receive appropriate prophylaxis at birth, infants are unnecessarily exposed to the virus each year in our state. These infants are infected in the following ways: · The woman is tested in early pregnancy for HBsAg and is found to be negative. She develops HBV infection later in pregnancy but it is not detected, even though it is recommended by CDC that high-risk women be retested later in pregnancy. The infection is not clinically detected by her health-care provider so her infant does not receive hepatitis B vaccine or HBIG at birth. · A chronically infected pregnant woman is tested but with the wrong test, HBsAb (antibody to hepatitis B surface antigen), instead of HBsAg. This is a common mistake since these two test abbreviations differ by only one letter. Her incorrectly ordered test result is "negative," so her doctor believes her infant does not need post exposure prophylaxis. · The pregnant woman is tested and found to be HBsAg positive, but her status is not communicated to the newborn nursery. The infant receives neither hepatitis B vaccine nor HBIG protection at birth. · The pregnant woman is not tested for HBsAg either prenatally or in the hospital at the time of delivery. Her infant does not receive hepatitis B vaccine in the hospital even though the vaccine is recommended within 12 hours of birth for infants whose mothers' test results are unknown. · The pregnant woman is HBsAg positive but her test results are misinterpreted or mistranscribed into her prenatal record or her infant's chart. Her infant does not receive HBIG or hepatitis B vaccine. 7 · The mother is HBsAg negative but the infant is exposed to HBV infection postnatally from another family member or caregiver. In a 2002 survey of New York State birthing hospitals, cost of vaccine was identified as a barrier to vaccinating infants at birth by many hospitals. Through this new program, the department hopes to eliminate additional hospital costs for vaccine purchase while improving hospital compliance with recommended standards of care. Of course, the primary goal of the program is to eliminate transmission of hepatitis B. Questions or comments regarding the program may be directed to Elizabeth Herlihy, Perinatal Hepatitis B Program Manager at (518) 473-4437, or e-mail [email protected]

Birthing Hospitals Get Certificates of Excellence

Millard Fillmore Suburban Hospital in Williamsville is a recipient of a certificate of excellence for adopting a universal hepatitis B birth dose policy. From left are Walter Ludwig, President of the hospital, Mary Culp, Public Health Nurse, Erie County Department of Health, Anita Hardy, RNC, Director of Women's Services, Shari Logue, RN, Nurse Manager, Dr. Ralph Wynn, Site Director, Pediatrics, and Debra Hilfstein, Public Health Representative, New York State Department of Health.

The Kingston Hospital's Family Maternity Center was the setting for the awarding of a certificate of excellence. From left are Jennifer Fitzgerald, Nurse Manager, Linda McKenna, former Nurse Manager, Renee Nealy, Public Health Representative, New York State Department of Health, Jamie Hughes, Ulster County Public Health Nurse, and Sandra Horan, Vice President of Nursing at The Kingston Hospital.

Hepatitis Training Curriculum Created

Under the CDC-funded Viral Hepatitis Education and Training (VHET) Grant, the New York State Department of Health is developing and evaluating a comprehensive, modular, and skills building hepatitis training curriculum. This three-year grant project is guided by a National Advisory Council consisting of hepatitis experts from around the country. The curriculum consists of five core modules and six setting-specific or topic-specific modules including the following: Core Modules: · Hepatitis and the Liver · Overview of Hepatitis A · Overview of Hepatitis B · Overview of Hepatitis C · Viral Hepatitis: Risk Assessment and Tailored Harm Reduction Messages Setting- or Topic-Specific Modules: · Integrating Viral Hepatitis Services into HIV/AIDS Programs · Integrating Viral Hepatitis Services into Substance Abuse Programs · Integrating Viral Hepatitis Services into STD/Public Health Programs · Integrating Viral Hepatitis Services into Incarcerated Settings · Hepatitis A and B Vaccination · Co-Infection During 2005, the training curriculum will be rolled out nationally at 15 locations including sites in New York City, California, Arkansas, Texas, Mississippi, Florida, Georgia, Illinois, Oklahoma, Colorado, and Vermont. The twoday training can be tailored to meet the needs of specific audiences by including any combination of the above-listed modules, depending on the needs of the audience. For example, if staffers of an HIV counseling clinic would like to be trained in hepatitis integration and vaccination services for their clients, they may choose to be trained in the five core modules, as well as "Integrating Hepatitis Services into HIV/AIDS Program" and "Hepatitis A and B Vaccination."

New Hepatitis Materials Available for Consumers and Providers

The NYSDOH has developed new hepatitis A, B, and C materials as part of an educational campaign. The following free materials are now available: Know more about Hepatitis A and B ­ This is a poster providing information on the risks associated with hepatitis A and B. It encourages people to get vaccinated. (poster) NEW 3/04 ­ English order code # 1842 limit ­ 5 Hepatitis C does not discriminate ­ This is a poster providing information on the risks for hepatitis C and encouraging people to get tested. (poster) NEW 3/04 ­ English order code # 1843 limit ­ 5 Hepatitis A ­ Know the risks. Get vaccinated. ­ This is a magnet providing information on the risks associated with hepatitis A. It encourages people to get vaccinated. (magnet) NEW 1/05 order code # 1846 limit ­ 50 Hepatitis B ­ Know the risks. Get vaccinated. ­ This is a magnet providing information on the risks associated with hepatitis B. It encourages people to get vaccinated. (magnet) NEW 1/05 ­ English order code # 1847 limit ­ 50 Hepatitis C ­ Know the risks. Get tested. ­ This is a magnet providing information on the risks for hepatitis C and encouraging people to get tested. (magnet) NEW 1/05 ­ English order code # 1848 limit - 50 Materials may be ordered by mail at: NYSDOH Distribution Center, 21 Simmons Lane, Albany, NY 12204 or fax orders to (518) 465-0432. For a complete list of free hepatitis materials and order form please go to the NYSDOH hepatitis website at: index.htm

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Integrated Risk Assessment Tool Piloted in 7 County STD Clinics

A new form will help assess whether an STD client is at risk for STDs, HIV, and hepatitis A, B and C. The form, called an Integrated Risk Assessment, will standardize the collection of risk information for clients seeking services at STD clinics, and will assist clinic staff in identifying the appropriate services that clients should receive, such as hepatitis vaccination, STD testing, or HIV testing. A project team of NYSDOH staffers developed the form as part of a 2004 project. The standardized form will be helpful to local health department STD clinics because they currently use a different form for each disease or use forms that fail to identify all risks factors associated with STDs, HIV and hepatitis. The tool was piloted in seven upstate county STD clinics from April through September 2004. During the pilot, conference calls were held with participating counties to answer questions and discuss utilization, implementation and evaluation of the tool. Counties participating in the pilot included: Chemung, Broome, Niagara, Jefferson, Schenectady, Rockland and Warren. At the end of the six-month-period, the pilot counties and the project team conducted a comprehensive evaluation of the tool. The project team made the suggested revisions. Information from each of the forms completed during the pilot were entered into a database at DOH that will allow for analysis of the information collected and help determine the at-risk populations being served at STD clinics in NYS. A report of this analysis will be available to each of the participating pilot counties. Currently, the revised Integrated Risk Assessment tool is under final DOH review and should soon be available for use as standardized risk assessment for all STD clinics.

Certificates of Excellence

As of January 31, 2005, the following 55 upstate New York birthing hospitals have been issued Certificates of Excellence acknowledging their establishment of a policy to routinely immunize all newborns with hepatitis B vaccine at birth: Adirondack Medical Center, Saranac Lake Alice Hyde Medical Center, Malone Arnot Ogden Medical Center, Elmira Bellevue Woman's Hospital, Niskayuna Benedictine Hospital, Kingston Brookhaven Memorial Hospital, East Patchogue Brooks Memorial Hospital, Dunkirk Canton-Potsdam Hospital, Potsdam Carthage Area Hospital, Carthage Cayuga Medical Center at Ithaca, Ithaca Central Suffolk Hospital, Riverhead Chenango Memorial Hospital, Norwich Champlain Valley Physicians Hospital, Plattsburgh Claxton-Hepburn Medical Center, Ogdensburg Columbia Memorial Hospital, Hudson Community General Hospital, Syracuse Community Memorial Hospital, Hamilton Corning Hospital, Corning Crouse Hospital, Syracuse Faxton-St.Luke's Healthcare, New Hartford Good Samaritan Hospital, Suffern Good Samaritan Hospital, West Islip Huntington Hospital, Huntington Inter-Community Memorial Hospital at Newfane, Newfane Ira Davenport Memorial Hospital, Bath Kingston Hospital, Kingston Lakeside Memorial Hospital, Brockport Lockport Memorial Hospital, Lockport Mary Imogene Bassett Hospital, Cooperstown Massena Memorial Hospital, Massena Medina Memorial Health Care System, Medina Mercy Medical Center, Rockville Centre Millard Fillmore Hospital, Buffalo Nassau University Medical Center, East Meadow Nathan Littauer Hospital, Gloversville Newark Wayne Community Hospital, Newark Niagara Falls Memorial Medical Center, Niagara Falls Oneida Healthcare Center, Oneida Oswego Hospital, Oswego Phelps Memorial Hospital Center, Sleepy Hollow Putnam Hospital Center, Carmel Rome Memorial Hospital, Rome Samaritan Hospital, Troy Schuyler Hospital, Montour Falls Sister's of Charity Hospital, Buffalo Sound Shore Medical Center of Westchester, New Rochelle St. Charles Hospital, Port Jefferson St. Clare's Hospital, Schenectady St James Mercy Hospital, Hornell St Joseph's Hospital Health Center, Syracuse United Memorial Medical Center, Batavia Westchester Medical Center, Valhalla WCA Hospital, Jamestown Women and Children's Hospital, Buffalo Wyoming County Community Hospital & Nursing Facility, Warsaw


These two articles emphasize the importance of establishing long term

Forging New Relationships

Vaccines for Pies in Seneca County

By Mary Jo Flynn, RN Seneca County Health Department

The Amish Home Immunization Program (AHIP) is thriving in Seneca County. This has not occurred overnight. This growing program is the end result of much hard work by a few dedicated and persistent nurses. These nurses started out traveling many county roads that saw more horse-andbuggy-travel than cars. These nurses started out door to door. In 1987, there appeared to be an influx of Amish families to Seneca County. This was bolstered by the vast beauty of this area situated in the middle of the Finger Lakes (framed by Seneca and Cayuga Lakes) and the rich farmland. A Seneca County Public Health Nurse initiated this program by meeting with the elders of the Amish community to educate them on the benefits of immunizations. At that time, there were approximately 19 Amish families in the county. Initially, families accepted a select few of the immunizations offered. One of the families had a child diagnosed with polio many years before. It was through that family's encouragement that others in the community began to accept polio vaccine. Eventually, familiarity and trust paid off and some families began to accept more immunizations and would then refer other Amish families to the nurses. At first, the most widely accepted vaccine was the DTP. This was probably due to the fact that there had been some pertussis in Pennsylvania. Many of the Amish families in Seneca County are from Pennsylvania and they frequently travel there to visit family members. In December 1998, an Amish child in Seneca County was born deaf and blind as a result of congenital rubella syndrome. Consequently, the community gathered all of the older unmarried girls and lined them up in their homes to receive the MMR vaccine. The Amish Home Immunization Program was able to facilitate the enrollment of the infant with congenital rubella into Happiness House, which provides services to the developmentally disabled and requires an updated immunization record for admission. The child's family accepted the immunization services, as well as services from the Rochester School for the Blind, precisely because similar services were initially provided in their own environment. Currently, the Amish Immunization Program has 60 children enrolled and the number continues to grow monthly. Infants as young as eight weeks are being started on immunization schedules. Adult family members are also accepting Td and MMR immunizations. Since the program's inception,five different nurses have successively taken on responsibility for these families. Building trust and maintaining continuity have been instrumental in the growth of AHIP, even while other immunization clinics in Seneca County are showing decreased utilization (as is the goal with families finding their "medical home"). This is in no small part due to the willingness of the county nurses to become familiar with the Amish families and to accept their cultural differences. That trusting relationship has paved the way for the community's receptiveness to other public health programs as well. For example, the Seneca County Health Department received a grant from the New York State Department of Health for the prevention of fire-related injuries. Through encouragement from the immunization nurse, many Amish families accepted free smoke alarms and allowed fire department personnel to come into their homes and install them. Part of the program included fire safety education, which benefited the families as well as the fire departments. The county is also educating the families about lead in the water and the environment and has provided bottles and instructions for collecting water samples from their wells. A public health sanitarian will then make a home visit to collect these water samples and identify wells with a high lead level. If indicated, the children will be referred for lead testing and the families provided with treatment recommendations and options. However, lead testing is not something that the Amish families have accepted routinely. What started out as a drop-in visit to one Amish home to offer immunizations has grown into a very successful, rewarding program. There have been minimal obstacles to providing these services and the benefits are tremendous to all involved. I have truly enjoyed servicing the needs of the Amish families and have been very fortunate to earn their trust and respect. I feel that I have made a difference. It is very rewarding to be greeted with a warm smile and a fresh baked pie or two!


s -- The Amish Connection

relationships with New York States diverse and hard-to-reach populations.

Herkimer and Otsego Respond to Pertussis

The receipt of a simple phone call, about a four-month-old infant with a positive test result for pertussis, led to the enhancement of a relationship with the Amish community in Herkimer and Otsego Counties. The staff from Otsego County received the call on December 23, 2004. It was able to respond to the immediate needs of the infant's family through phone calls and contacts with the community elder. It was determined that a home visit would be more effective so that contact information and treatment needs could be met. Due to the upcoming holiday weekend and their religious celebration, all assessments and delivery of medication had to be completed by Christmas Eve. The family had no primary physician or transportation. Otsego County provided the necessary treatment and prophylaxis to the family. It was also able to obtain information on a symptomatic 14-yearold cousin who had been in Pennsylvania and received a letter stating she was exposed to pertussis. She had been symptomatic and cared for the unvaccinated infant. The community elder was given the necessary information and asked to share this with the community so other potential cases could be identified. This community consists of about 30 families and is located in both Herkimer and Otsego counties. The two counties shared the information and proceeded with their own investigations. After the holiday, Herkimer County contacted the community and learned that there may be another family with a coughing illness who had visited Delaware. It was at that time that they decided it would be more effective to visit the community and test symptomatic individuals and arrange for their treatment or prophylaxis. The elder also voiced interest in their county clinic schedule and they felt it would be a good opportunity to enhance their relationship with these families. The county visited 10 families. Winter cold, snowy roads and short daylight hours greeted the nurses but they were very successful. They obtained six nasopharyngeal swabs from symptomatic children who were exposed to the source case. During these lengthy visits, the nurses were able to talk with the families and provide information on pertussis and immunization, as well as to review health records. Many families were receptive to further immunization and a community "catch up" clinic is being considered, as well as regular contact to keep them notified of available county services. The other outcome of this visit was the identification of the diversity within the community. Many families accepted medical intervention but many did not. However, the education and care the nurses offered was well received by the whole community. Both the Pennsylvania and Delaware state immunization programs were contacted. Pertussis is currently a serious problem in many Amish communities in both states. A problem alert was posted in December to notify all counties that this population may be exposed throughout the state. The nasopharyngeal swabs were all negative but the investigation is ongoing. Families have been in contact with the county with reports of coughing illnesses and appropriate follow up has been recommended. The amount of work provided by both counties to this community has helped to establish a working relationship with these Amish families.

Herkimer Otsego


The Registry Can Make PBIIs Quick and Easy

By Linda Markell Public Health Educator, Onondaga County Health Department

Onondaga County Health Department staff members have taken part in Provider-Based Immunization Initiative (PBII) assessments since 1997 to measure county-wide and provider immunization coverage rates of one and two-yearold children. Provider offices are scheduled for one-day medical record reviews. Data are entered from a sampling of charts into the Clinical Assessment Software Application (CASA). CASA is the tool developed by the Centers for Disease Control and Prevention which provides reports and specific immunization coverage levels to the county staff and providers. HealthyShot, the software program designed for the Central New York Immunization Registry (CNYIR) by Partners in Health Systems, allows providers to download Registry immunization data directly into CASA format. Nora Jones, a Certified Medical Assistant (CMA) at St. Joseph's Westside Health Center, Syracuse, demonstrated how quickly and easily a PBII can be accomplished during a December 2004 assessment. Nora understands and utilizes the many reporting features of the CNYIR, making it a valuable tool for her practice. Because it only takes a few quick clicks of the computer, she does routine CASA assessments every three months to catch children who may be behind in their immunization coverage. The Westside Health practice serves a very diverse population with languages such as Ukrainian, Spanish, and Somalian, and the CNYIR has been a great help with keeping children's immunizations up-to-date. For more information about the CNYIR, call Susan Anderson, Partners in Health Systems, at (315) 446-1612 x7227 or Kathy Mogle, Public Health Educator, Onondaga County Health Department, at (315) 435-3280.

Nora Jones, CMA, St. Joseph's Westside Health Center, and Wendy Czajak, Onondaga County Health Department IAP Community Health Nurse, show how quick and easy a PBII can be.

New Audit Targets Randomly Selected Grades

New York State Public Health Law Section 2164 requires all students, except those legally exempted, to be adequately immunized against certain vaccinepreventable diseases for school entry and attendance. In order to monitor compliance with this law, the Immunization Program has developed a questionnaire to audit annually the immunization status of randomly selected grades. This survey is in addition to the routine annual survey that the Immunization Program completes of all students entering school in New York State for the first time. The questionnaire is mandated under Section 206(e) of the Public Health Law, which empowers the Commissioner of Health to obtain, collect and preserve information relating or contributing to the promotion of health and security of life in the state. The eighth grade has been chosen this year as the first additional grade to be surveyed. The questionnaire will be sent out every February with a required return due date of March 31. It should be completed with a number-two pencil and signed by the person charged with its completion. Instructions will be enclosed with each questionnaire. It will be sent only to those New York State schools, both public and private, containing the grade level selected each year. Anyone desiring more information or assistance may call David Gonzalez or Robin Tice at (518) 474-1944. 14

Hospital Rewarded for 90% Coverage Levels

The Maternal Child Health Center Pediatric Office at St. Joseph's Hospital received a New York State Department of Health Certificate of Excellence for reaching 90% of immunization coverage levels of its two- year-old patients. Takina Sinclair (left), Onondaga County Outreach Worker, presents the award recognizing excellent performance to pediatric nurse Nan Santoro (foreground). Also, from second from left are pediatric nurses Carol Pelrah, Martha Evans, Rebecca Wright, Ann Brazell and Nurse Coordinator Kay Powell. Absent from the picture are pediatric nurses Cindy Kosturik and Patricia Charette.

Provider Based Immunization Initiative (PBII) Certificates of Excellence

Each issue of the New York State Immunization Update will announce the names of health-care providers awarded Certificates of Excellence for their immunization coverage levels of two-year-old children. The Certificates of Excellence are presented through the Provider Based Immunization Initiative (PBII) to health-care providers who have achieved high immunization levels of their twoyear-old patient populations. The New York State Commissioner of Health and either the President of the American Academy of Pediatrics District II or President of the New York State Chapter of the American Academy of Family Physicians (depending upon the specialty of the provider), sign the certificates. Certificates of Excellence have been presented to the following practices or physicians: David Ashe, MD, FAAP, Pleasantville, NY Alan Barcomb, MD, Oakfield, NY Ralph Candela, MD, New Rochelle, NY Qutubuddin Dar, MD, Warsaw, NY Jeannine L. Dolan, MD, Ontario, NY Linda Paine Hughes, FNP, Oakfield, NY Marlene Hajal-Mouaikel, MD, Gouvemeur, NY Andrew Satran, MD, Pomona, NY Neal T. Smith, MD, Ontario, NY Ann M. Sweet, RPAC, Warsaw, NY Arcadia Family Practice, Marion, NY Amber Birkland, PA Giridhar Kamath, DO Joyce Lester, NP David Stobie, PA Bassett Health Care ­ Morris Karen Adams, FNP Regina White, LPN Batavia Pediatrics, Batavia, NY Lalit Jain, MD Briarcliff Pediatrics, Briarcliff Manor, NY Carmel Pediatrics, Carmel, NY Virgilio Monteleone, MD, FAAP Child Health Care Associates, East Syracuse, NY James Brown, MD Vito Losito, MD Rebecca Potter, MD Kathleen Stoeckel, MD Children's Hospital of Buffalo Teen Tot, Buffalo, NY Dalinda Condino, MD Chili Center Family Medicine, Rochester, NY Depew-Lancaster-Cheektowaga Pediatrics, Depew, NY Genesis Pediatrics, Rochester, NY M. Christine Arigo, MD Catherine Goodfellow, MD David Sullo, MD Elizabeth Walsh, MD Hassan Medical Group, Albion, NY Ghulam Mustafa, MD Irene A. Burns, MD, Batavia, NY Kathleen Parker, NP Le Roy Family Medical Care, PLLC, Le Roy, NY Thomas Ball, MD Robin Shaw, ANP Rachel Zickl, FNP Main Street Pediatrics, Cambridge, NY Seema Chaudhari, MD William Figlozzi, MD Jeroy Motsiff, PNP George Ruta, MD Ogden Pediatrics, N. Chili, NY Charles Bruehl, MD Michelle Kerr, PA Mark Klier, MD Pediatric and Adolescent Health, M.D., P.C., Johnson City, NY Christine A. Burke, MD J. Roger Chatterton, MD William J. Miller, MD Southern Tier Pediatrics - Horseheads, Horseheads, NY St. Joseph's Family Health Medical Center, Yonkers, NY

Internet Resources

New York State Department of Health New York State Office for the Aging Centers for Disease Control and Prevention Recommendations of the Advisory Committee on Immunization National Coalition for Infectious Diseases National Foundation for Infectious Diseases American Society of Consultant Pharmacists


NYSDOH Immunization Program Room 649, ESP, Corning Tower Albany, NY 12237-0627






Immunization Update - Spring 2005, New York State Department of Health

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